HomeMy WebLinkAboutSHANE LEE ESTATES BLK 2 LT 4Shane Lee
Estates
Block 2
Lot 4
#014-061-72
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DEPARTMENT
_-
DEF`ARTME N•d..T OF HEALTH AND EN•NV I RON•dN,(EN•d'TAL. r'RO T E � T� I C�('•d
=25 'L' STREET, ANCHORAGE, All,.'. 9950:1-
279-25-1:1 ? -1:
L--9 FE L— g F=^ F- F-' f'4 1 7-
PERMIT
AF'F'L I CAN'T EDWIN R i hINE'R 8-3:10 WELLSLEY CT - °44— =1 ::1 -
LOCATION
LEGAL Le$ E_„2 SHANE LEE ESTATES LOT SIZE 80Pi0 SQUARE FEET
M I N�d I N'iUM DISTANCE BE TWEEN�d A WELL AND ANY ON.d—W I T'E 5-EWA('3E. D I'ESPO ,AL '=•`r STEII I: .
J.00 FEET FOR A PRIVATE WELL OR 200 FEET FOR A PUBLIC WELL.
WELL LOGS !IRE RE�_H_!IRED AND MUST BE RETURNED TO THE=. DEPART'h1ENdT LdITH.I('d :`k` L A'r`
OF THE WELL COMPLETION.
SPECIFICATIONS AND CONSTRUCTION STRUC:'TION'd DIAGRrRi` ARE AVAILABLE TO INSURE' PROPER
IN• STALL_AT ION•d.
F" &::- F°'" 1-9 T -T' °^"^° F-fi L_ .1 F-�x F'- A._A F;;�' A_...0 r -j F.- o -e E_ !=:R F-'° F= F;;_, A --A Irl 1 ` :j; "=" @_8 I-
I CERTIFY THAT
1: I AN FAMILIAR WITH 'THE. REC',!U T REMENTS FOR ON•d—SITE SEWERS AND WELL� AS SET
FORTH r.`,-` THE MUNICIPALITY OF ANCHORAGE.
: I WILL I • " "ALI_ 'THE S'T'S•'1 IN AC:CORDAN•dCE. WITH THE CODES.
SIGN•aED
- Municipality of Anchorage // 171?
On-Site Water 907an34aste04ter Program (
Certificate of On-Site Systems Approval %
\-°;mss
Parcel I.D. 014-061-72 Expiration Date: /-
1.
GENERAL INFORMATION
Complete legal description Shane Lee Estates Block 2 Lot 4
Location (site address) 6711 Tiffany Terrace
Current Property owner(s) Alaska USA Federal Credit Union Day phone
Mailing address 425 Phillips Blvd Fc-236 Ewing, NJ 08618
Real Estate Agent Day phone
2. TYPE OF DWELLING:
E Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 5
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well Q Individual ❑
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer
WaiverNariance request for: Distance:
Received byL, , V, bj '10 Date: / .(3/ ,7-0/i
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $ 504, Waiver Fee $
Date of Payment IO/2ô/i? Date of Payment
Receipt Number 66-0356 Receipt Number
COSA# 43 CI'?105 Waiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined
in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater
disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply
and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances,and regulations in effect at
the time of installation.
In conducting an adequacy test,I attempt to provide a thorough,conscientious engineering analysis of the system in accordance with MoA COSA
guidelines and regulations.The reported results describe the performance of the system under the conditions encountered at the time of the test,
and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil
condition,ground water levels that may fluctuate during the year,and the water usage of the family being served by the system.These conditions
are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future
performance of the system,nor do they guarantee that there are no hidden defects or encroachments.Therefore we cannot provide any warranty
for future performance, nor can,we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed
above.
Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218
Address P.O. Box 100217, Anchorage Ak. 99510
Engineer's Printed Name Steven R Pannone Date 10/18/2017
��OF A•gss• k
0*TTH
6. DSD SIGNATURE I�
System #1 Approved for `� bedrooms •Sev R. nnone: 1
CE-8149• . ' '
System#2 Approved for bedrooms .
•'�v�
Disapproved ,k1 PROFESS40NA� 'r
Conditional approval for bedrooms, with the following stipulations:
"Cys``
`J= ON-SITE
=� WATER �,"
AND R'
ct WASTEWATER o
PROGRAM U,
god �a
SERV�C
y� ( '� �— Original Certificate Date:
I C9 -Z6 / 7
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet r c
If more than 1 septic system is on the lot:
COSA Checklist# 1 of -
Structure served by this system 1
Certificate of On-Site Systems Approval Checklist
Legal Description Shane Lee Estates Block 2 Lot 4 Parcel ID. 014-061 -72
A. WELL DATA
Well type Private If A, B, or C provide PWSID # Well Log (Y/N) Y
Date completed 1125/1978 Sanitary seal (YIN) Y Wires properly protected (Y/N) Y
Total depth 96 ft. Cased to 40+ ft Casing height (above ground) 12+ in.
FROM WELL LOG AT INSPECTION
Date of test 1/25/1978 10/6/22/017
Static water level 20 ft. `/ ft.
Well production 25 g.p.m. 5 g.p m.
WATER SAMPLERESULTS:
Ni7�, , YU} t ND
Coliform col niesl100 mL Nitrate mg/L
Arsenic ND ug/L Date of sample_ 10/6/2017 Collected by: PES
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Date installed
Tank size gal. Number of Compartments Cleanouts (Y/N)
Foundation cleanout (YIN) Depression over tank (Y/N) High water alarm (YIN)
Date of pumping Pumper
C. ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d./ft2 or ft2/bdrm) System type
Length ft. Width ft. Gravel below pipe ft
Total depth ft Eff. absorption area ft2 Monitoring tube Depression over field
Date of adequacy test Results (Pass/Fail) For bedrooms
Fluid depth in absorption field before test in. Water added_ gal. New depth in
Elapsed Time: min. Final fluid depth in. Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at in. "Pump off' level at in High water alarm level at in.
Datum Cycles tested Meets alarm&circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO
Septic tank/lift station on lot 100+ On adjacent lots 1 00+
Absorption field on lot 100+ -- On adjacent lots 1 00+
Public sewer main 75+ Public sewer manhole/cleanout 100+
Sewer/septic service line 25+ Holding tank 100+
Animal containment areas 50+ Manure/animal excrete storage areas 100+
SEPTIC/HOLDING TANK ON LOT TO
Building foundation Property line Absorption field
Water main Water service line Surface water
Wells on adjacent lots
ABSORPTION FIELD ON LOT TO
Property line Building foundation Water main
Water Service line Surface water Driveway, parking/vehicle storage
Curtain drain Wells on adjacent lots
F. COMMENTS
Survey on file.
G. ENGINEER'S CERTIFICATION .►��`�"�\
I certify that 1 have determined through field inspections and
review of Municipal records that the above systems are in t* 49 TH N.
'51 0,
conformance with MOA COSA guidelines in effect on this date. / •••,,•, i•• 1
Ii
• —_
Engineer's Printed Name Steven Pannone .Steven ISonnone.• •
0 . CE-8149 • ���
Date 10/18/2017 s•
COSA canary sheet_2-6-15 doc
Municipality of Anchorage
Development Services Department
Building Safety Division
Onsite Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 014- Q i-1 COSA# C Q22('
1. GENERAL INFORMATION Expiration Date: Z 0 —9-07
Complete legal description
Location (site address)
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
SHANE LEE ESTATES LOT 4, BLOCK 2
6711 TIFFANY TERRACE • ANCHORAGE. AK 99507
PAUL EDWARDS Day phone C/0 AGENT
Day phone
BOB BAER w/ DYNAMIC PROPERTIES Day phone 261-7505
3111 "Co STREET • ANCHORAGE. AK 99503
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Individual Well
0
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
❑
Individual Holding tank
❑
Community On-site
❑
Public Sewer
0
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given In paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer
of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or
water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems
Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may
be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions In the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the
information obtained from the Municipality of Anchorage riles and from my investigation and inspection, the
on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm GARNESS ENGINEERING GROUP, Ltd.
Address 3701 E. TUDOR ROAD, SUITE 101 a ANCHORAGE, AK
Engineers Printed Name
Engineers Comments:
JEFFREY A. GARNESS, P
In conducting this evaluation, GEG, LtD. attempted to provide a thorough,
conscientious engineering analysis of the system In accordance with ADEC and MOA
DSD Guidelines 8 Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test, and separation
distances measured to readily Identifiable features. The operational life of all wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, LTD. can therefore not provido
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party is not authorized, nor will it confer any legal right whatsoever.
5. DSD SIGNATURE
Approved for _y_ bedrooms.
Disapproved.
Phone 337-6179
Date b O�
'••ey A. orness:'
' I� .. �
Ccy-79r53 eL
ure �0 ���G
4Q1\� a �•
Conditional approval for bedrooms, with the fllowing stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Reort
Other
J`QP .,....,,;.,/0
ON-SITE
WATER AND •:
WASTEWATER
PROGRAM
By: Original Certificate Date: %�
(Rm 11105)
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water 8 Wastewater Program
4700 Bragaw Street
P.O. Bou 196650
Anchorage, AK 99519-6650
www.muni.wglonsdo
(907) 343.79W
CERTIFICATE OF ONSITE SYSTEMS APPROVAL CHECKLIST
Legal Description: SHANE LEE ESTATES, LOT 4, BLOCK Parcel ID: 0 I
A. WELL DATA ' ASSUAIED(UPON SURROUNDING WELL LOGS
Well type SATE If A, B, or C provide PWSID# N A
Date completed 1/25/1978 Sanitary seal (YM) YES
Total depth 96 ft. Cased m '40+ ft,
FROM WELL LOG
Data of test 1/25/1978
Static water level 20 ft.
Well production 25 g.p.m.
Well Log (Y/N) YES
Wires properly protected (Y/N) YES
Casing height (above ground) 12+ in.
AT INSPECTION
7/3/2007
30 ft.
5 —g -P.M.
WATER SAMPLE RESULTS:
13
Coliform 4b oolonies/100 ml. Nitrate-W,
itrate mg./L. Other bacteria colonies/100 mi.
Arsenic:2_ o}ug./L. Date of sample: 7/2/2007 Collected by: GEG Ltd.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material
Tank size gal. Number of Compartments —
Foundation cleanout (YM) — D at tank (YIN) —
Date
C. ABSORPTION FIELD DATA
Date installed
Length ft.
Pumper
Date installed
High water alarm (YIN)
Soil rating (g.p.dAYor ft'/bdrm)— System type
Width
Total depth ft. Ert. absorption area_ ft'
Date of adequacy test
ft. Gravel pipe ft.
Depression over field—
For—bedrooms
eld
Forbedrooms
Fluid depth in absorption field be — in. Water added —gal. New depth —in.
Elapsed Time: Final fluid depth— in. Absorption rate >= g•p.d•
An enation treatment (past 12 mo.) (Y/N 8 type) If yes, give date
D. LIFT STATION
Date installed
"Pump on" level at —in.
E. SEPARATION DISTANCES
Size In gallons Manhole/Access (Y/N
"Pump off- leve Hlgh water alarm level at in.
Cycles tested Meets alarm & circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100'+ On adjacent lots 100'+
Absorption field on lot 100'+ On adjacent lots 100'+
Public sewer main 75'+
Sewer /septic service line 25'+
Public sewer manhole/cleanout 100'+
Holding tank N/A
Animal containment areas 500+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation Property line Absorption fie
Water main Water se Surface water
Wells on a '
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line Building foundation Water main
Water service line Surface water Driveway, parking/vehiole storage
Curtain dre' Wells on adjacent lots
F. COMMENTS
G. ENGINEER'S CERTIFICATION OF q
I certify that I have determined through field inspections and �• y*
review of Municipal records that Me above systems are in """ ' ' ''"•' .. • "' •"'
conformance with MOA COSA guidelines in effect on this
date. J ray orness. G
Engineer's Printed Name JEFFREY A. GARNESS 0 ., CC —7953 `J
Date b/b�
CASA Fee S 2`3O + 175 Rus N
Data of Payment
Receipt Number
(Rev. 11105)
Waiver Fee $
Date of Payment
Receipt Number
JUL-06-2007 Rle:3 m9NYmErOEPEE2E
p
FAX A 8785!7§54 m E
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ANALYTICA
GROUP
Gamess Engineering Group, Ltd.
Attn: Jody GEG, Ltd.
3701 E Tudor Road, Suite 101
Anchorage, AK 99507
907-337-6179
Fax: 907-338-3246
Client Sample ID:
Sampling location: 3711 Tiffany Road
Client Project: Valley Edge SID
Sample Matrix: Aqueous
COC a:
PWS#:
Residual Chlorine:
Comments:
Lab#: A0706392-OIA
Analytica International, Inc.
4307 Arctic Blvd.
Anchorage, AK 99503
Phone: 907-258-2155
Fax: 907-258-6634
Report Date:
7/6/2007
Receipt Date:
6292007
Sample Date:
72/2007
Sample Time:
9:50:OOAM
Collected By:
BM
Flat, Definitions:
MRL = Method Reporting Limit
MCL = Maximum Contaminant Limit
B = Present also in Method Blank
If = Exceeds Regulatory Limit
M = Matrix Interference
J = Estimated Value
D = Lost to Dilution
•• = RL higher than MCL; target not detected
TNC - Too Numerous to Count - result rejected
CF = Confluent Growth - result rejected
TCNG = Turbid Culture No Growth - rejected
Analysis Method Prep Prep Analysis
Parameter Result Units Flags MRL MCL Method Dale Date Analyst
DO.8/200.8 (Aqueous) - Family Well Water 1 Test was conducted by: Analy7ica - 7hornion
Arsenic 2.07 ug/L 0.15 JO 200.8 7/5/2007 7/5/2007 KS
Lab#: A0706392-OIB
Analysis Method Prep Prep Analysis
Parameter '- Result Units Flags I%IRL MCL Method Date Date Analyst
4500-NO3E (Aqueous) - Nitrate Test was conducted by: Analy?ica -Anchorage
Nitrate as N <MRL mg/L 0.10 JO 7/32007 7/32007 AJ
Lab#: A0706392 -OIC
Analysis Method Prep Prep Analysis
Parameter Result Units Flags MRL MCL Method Date Dale Analyst
Membrane
Bacteria, Other
Total Coliform
e F&—
Reported by: Krissy Plett,
Laboratory Project Manager
'iltration MF Test was conducted by: Analytica -Anchorage
<MRL CFU/IOOmL 1.0 722007 722007 PL
<MRL CFU/IOOmL 1.0 1 722007 722007 PL
Page I of I
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DAILY DRILLING LOG
PENN JERSEY DRILLING CO.
Anchorite, Aluk, "MI
OQMER OF LAND_Ll�V • l 11 ( K
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DATE -STARTED �f F ` �..i� CI �2,�! �11,i,� �I 7
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STATIC LEVEL OF WATER PT__ -L_.__
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GALS. PER
G'I '
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MUNICIPALITY OF ANCHORAGE
• '� DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel l.D. # HAA # IA Q `i 20f q21 —
1. GENERAL INFORMATION
Complete legal description Lot 4; l3tock 2 Skine Lee: Subdivision
Location (site address or directions) 6711 Ti44any Tenaace
Anchonaae AK 99507
Property owner David and Robbin Wangaand Day phone (w) 349-9641 David
- 349-1602
Mailing address 6711 TiA4anv y Tennace Anchongge AK 99507
Lending agency Nonthtand Mo,%taanfflonna_ N. Day phone 274-5150
Mailing address 2605 Denati. #100
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 4 '\1
3. TYPE OF WATER SUPPLY:
Individual well XXX
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Puou ourlur """
V
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
5.
G'3
0
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I furtherverify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm s & s
Eagle
Address
Engineer's signature
No. 2D4
DHHS SIGNATURE
Approved for �� bedrooms.
Disapproved.
Conditional approval for
Additional Comments
Phone G q `f 2`.y -
DateL �/ 3
bedrooms, with the following stipulations:
Date � -1 _ 93
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Beck MOA W21
Municipality of Anchorage
Department of Health & Human Services M'+
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L67 4- 6U< Z 5,4A -)%1f- LE e� f L Parcel I.D.
A. WELL DATA
Well type ed NATE" If A, B, or C, attach ADEC letter. ADEC water system number "ItIIA
Log present 6N) `%�-S Date completed DrillerasNN JE�sgy DIULi o
Total depth / Cased to 4o rt Casing height Z4�r
Sanitary seal&) y�S Wires properly protected Cy --)V)
Date of test
Static water level
Well flow
FROM WELL LOG
20'
ZS g.p.m.
AT INSPECTION MUNICIPALITY OF ANCHORAGE
ENVIRONMENTAL SERVICES DIVISION
1993
;i ia q 8
Z3
RaEIVED
Pump level POT X/JowN PUMA N07- /2L-7gCHe-Z>
SEPARATION DISTANCES FROM WELL TO: MU/✓tQP-F4t-
Sof lEl2,
Septic/holding tank on lot ONE PRESEAS ; On adjacent lots No/ PK�S�N%
AT
Absorption field on lot NoaJ pKESEN% ; On adjacent lots
Public sewer main g% + Public sewer manhole/cleanout
Sewer service line
WATER SAMPLE RESULTS:
Coliform d
Petroleum tank AIOAvtF IWDuN
Nitrate 'Other bacteria
Date of sample: 6 /Z/ 1 3 Collected by: �-S e/V G�6V6 GcxwyA
B. SEPTIC/HOLDING TANK DATA N01,)6- pne-SEAl%, MU1ii(1r19L SEr, ere,
Date installed
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Tank size
Foundation cleanout (Y/N)
Compartments
Alarm tested (Y
SEPARATION DISTANCES FROM SEPTIC/IJ.C�NG TANK TO:
Well(s) on lot
To property line
Sur water/drainage
72-026 (Rev. 7/91) Front
adjacent lots
Absorption field
Depression
Foundation
Wafer main/service line
CONTINUED ON BACK PAGE
C. LIFT STATION /JOP6- Clt6/el(- SC -We'll
Date installed Manufacturer
Size in gallons Manhole/Access
Vent (Y/N) "Pump on" level at "Pump off' level at
High water alarm level Cycles tested
Meets MOA electrical codes
SEPARATI
W n lot
ANCE FROM LIFT STATION TO:
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA ,J6/JE f°94!�-SEW - M(U?J1Cl{/ML S6w6�K,
Date installed
Length Width
Total absorption area
Depression over field (Y/N)
Results (pass/fail)
Peroxide treatment (past 12 months) (Y/N)
Soil rating _ System type —
Gravel thickness Total depth
Cleanouts present (Y/N)
Date of adequacy test
for
give date
SEPARATION DISTANCE FROM ABSORPTION FIEL "f O:
Well on lot On ad' t lots Property line_
To building foundation To existing or abandoned system on lot
On adjacent lots Cutbank Water main/service line.
Surface wate Driveway, parking/vehicle storage area
Curta f drain
E. ENGINEER'S CERTIFICATION
I certify that I have checked,yer
Signature
Engineer':
Date —
bedrooms
or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
land NO 204
99577" —
ti �•r a�sr .. `;1, airr ,
t
D
HAA Fee $ ab o
Date of Payment 6,
Receipt Number �2 4.
72-026 (Rev. 3/91) Back MOA 21
Waiver Fee: $ —
Date of Payment
Receipt Number
06/07/93 14:48 CT&E ENVIRONMENTAL LAB SERVICES
COMMERCIAL TESTING & ENGiNEERINP CID.
ENVIRONMENTAL LABORATORY SERVICES
AINCR ,°°° REPORT of ANALYSIS
Chemlab Ref.# :93.2523-3
Client Sample TO &L4 B2 SHANE LFA: S/D
Matrix :WATER
NO. 054 1?03
5633 6 STREET
ANCHORAGE, AK 99576
TEL' (907) 5622343
FAX (907) 561-6301
Client Name :S & 5 ENGINEERING WORT: Order :66737 ,,.
Ozdl~red By :R. SHAFER Report Completed :06/07/1 -
Project Name Collected :06/02/93 @ 15:24 hr:
project# Received :06/02/93 @ 16:30 hr:.
PWSID :UA technical Director: E C. EDE
1 eleased By :
Sample Remarks: ROUTINE SAMPLE COLLECTED SY: S.S
QC #,? ,tabls Ext. Anal
Parameter Results Qual Units Method Limits Date Pate Init
----------------------------- I -------------------------------------- __—-----------
Nitrate --N 0.10 U mg/L --"nA1353-2/3300-0 10 06/03 CMF
UA = Unavailable
x
nye Sr��eia1 Ss���ructi6P�5 Abuvp
gee SUPle RHOS ADOVe
MA
= MV A001yZca
U R
Undetected, Reported value IS the
practical qua(Itification limit.. LT =
Less Than
D =
Secondary dilution.
GT =
Greater Than
It% G Member of the SGS Group (800iM6 G4n6rale de Surva111an0a)
FNVIAANMFNTAL SERVICES IN ALASKA, COLOPIA00, UTAH, ILLINOIS; OHIO, MARYLAND, WEST VIRGINIA, NEW JERSEY, SOUTH CAROLINA
` 06/07/93 CT&E ENVIRONMENTAL Lai? SERVICE3
t 05 1706
WRING CO. AK DIV
COALWERCIAL TESTING & ENGINE
FI E:LErHONE (907) 562-2343 5633 6 Sliset
Anchorage. Alaska 99519
Drinking Water Analysis Repon for Total Coliform Bacteria
TO BF COMPLETED BY WATER SUPPLIER
❑ PUBLIC WATER SYSTEM I,D. k _I —_J
PRIVATE WATER SYSTFM
Na" p;lr4e Na.
M, inq Add,;.a
SAMPLE
Mo. Day Year
SAMPLE TYPE:
iii Routino
❑ Check
with lob ref. no.__.._7realoc t-rsrur
❑ Spec! --o! four;>r�ar; U ,trodto-o' Vjrtgr
SAMPLE
No. LO CAT$Q i
-Z
- —
a-- - — - -- ----- -- — --
i
READ INSTRUCTIONS
BEFORE
To BE COMPLETED B( LABORATORY
1➢
jIf Anaiysi4 shows this Water SAMPLE to be:
I !r`
,� Satls`,jctary
— --Of U :satisfactory
J wam!a'oa ions, in transit; sample should
nct rx over 3U i,eurs old at examirtat&
to re',e6!e reSUitS. F.sase nerd
�'. c•11' S ti �`.�i18 via. SpoOlai do!ivery mail.
Tims Rscnived __—Q
b.rs'yi!; st wra'hac! mlambe2na Filter
,d ! r:ia 4?sf. i`Is�. i-onu!,•
ils�e:l"IrF3IC>L.UC!C:r t. 1h'ATIVR ANALY-SiS Rr-100RD
Metht}rena Filter: D110<1 C-5unt_.--
Varif!catiau:
Frcal Coliform Conthmmflon
0011form/1DO ml
COLLECTING SAMPLE; r ���u!ts _ ------ ---- _ - comorm/100m1
Fihat dfem6r&ns FIf a /
_ (1 ` Date
Resorted f1jr�. ia,J La';y.
WITC W n Nuroorourb Td Gount ,r�e: ,,
P.M,
OB < Other Bacteria
PART ONE OF T Wil
i
t
TELEPHONE
GSAL A GEOLOGICAL LABORATORIES OF Alp"M INC. 1907) 279.4014
P.O. BOX 4.1276 ANCHORAGE, ALASKA 99509 4849 BUSINESS PARK BLVD.
uuawtofnes
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
SAMPLE DATE: LTJ FTKI
Mo. Day Year
SAMPLE TYPE:
❑ Routine
❑ Check Sample (for routine sample El Treated Water
with lab ref. no. ) El Untreated Water
E3 'Special Pur)oose
SAMPLE - Time Collected
NO. LOCATION Collected By
2 J46-?(� 6Q-'- SAD
3 1
4
5
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Form No. 18.310 (3-78)
06-1220 (b)
Rev. 1978
Date Collected
Date Received
Presumptive
24 Hours
48 Hours
Confirmatory
24 Hours
TO BE COMPLETED BY LABORATORY
LABORATORY:
NAME
ADDRESS I
Date Received
Time Received / 3b
Analytical Method:
❑ Fermentation Tube
Membrane Filter
Lab Ref. No. Result' An lyst
i � m
(mI
- No. of Colonies 1100 ml. or No. of Positive portions.
BACTERIOLOGICAL WATER ANALYSIS RECORD
Multiple Tube Report:
Membrane Filter: Direct Count
Verification: LTB
Final Membrane Filter RReA "
Reported By
_Time Received.
10mi ioml
Source
a.m.
p.m. Lab.No.
—
lOml I loml I loml
1.0m1 O.lml
Broth 24 hours: Broth 48 hours:
10ml Tubes Positive/Total 10ml Portions
Coliform/100mi
BGB
Date
a.m.
p.m.
MUNICIPALI
MUNICIPALITY OF ANCHORAGE
I Y Ul-
DEPT. G
- DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTdOMIRONIY,ENTAL Pk.;. -CTION
- 825 L Street - Anchorage, Alaska 99501
Z
STREET LOCATION
ENVIRONMENTAL ENGINEERING DIVISION
Telephone 264-4720
RECEIVED
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWERFACILITIES
DI RECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTYOWNft
PHONE
❑ MULTIPLE FAMILY
•"Three ❑ Six
7. WATER SUPPLY
MAILING A DRESS -
-
z � �r
❑ COMMUNITY
OPERTY RESIDENT (If different from above)
❑ PUBLIC UTILITY
PHONE
NLS bti G�
O INDIVIDUAL/ON-SITE**
2. BUYER
PHONE
MAI LING ADDRESS -
by this Department.
3. LENO
INSTIT TION
PHONE
L✓
MAILING ADDRESS
4. REALTOR/A7
PHONE
MAI LING ADDRESS
5. LEGAL DESC IP N
Z
STREET LOCATION
-
�f
6. TYPE OF RESIIJENCK
NUMBER OF BEDROOMS
r[7 SINGLE FAMILY
❑ One ❑ Four ❑ Other
❑ Two ❑ Five
❑ MULTIPLE FAMILY
•"Three ❑ Six
7. WATER SUPPLY
INDIVIDUAL*
*ATTACH WELL LOG. Awell log is required for all wells drilled
❑ COMMUNITY
since June 1975. For wells drilled prior to that date, give well
❑ PUBLIC UTILITY
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
O INDIVIDUAL/ON-SITE**
**If individual/on-site, give installation date
If system is over two (2) years old an adequacy test is required
PUBLIC UTILITY
by this Department.
E: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
r
72-010(3/78)
O
THIS SIDE FOR OFFICIAL USE ONLY
INSPECTION APPOINTMENTS
DATE RECEIVED
TIME
TIME
TIME
DATE
DATE
DATE
INSPECTOR
INSPECTOR
INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE
❑ SINGLE FAMILY
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS
❑ ONE ❑ THREE ❑ FIVE ❑ OTHER
❑ TWO ❑ FOUR ❑ SIX
2. WATER SUPPLY
❑ INDIVIDUAL
❑ COMMUNITY
❑ PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
❑INDIVIDUAL/ON -SITE
El PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATE INSTALLED
INSTALLER
❑Septic Tank or ❑ Holding Tank
Size: _ If Tank is homemade
give dimensions:
SOILS RATING
TYPE OF TANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL
4.. DISTANCES
WELL TO:
Septic/Holding Tank
Absorption Area
Sewer Line
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
LL- APPROVED FOR BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE
1
BY (Tit
LEGAL DESCRIPTION
72-010 (Rev. 3/78)